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SAIN .TDAQi.M COUNTY <br />ENViRONIAE1,TALhEAL-iv D PA&INIENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 I'= (209) 468-3433 Web: www.sipov.org//ehd <br />UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />�� ct <br />Inspection Date: <br />z �f z 1 0 <br />l� <br />❑ mechanical Model: <br />Facility Address: , I <br />i S vj c� <br />Service Request #: <br />S R 00scIf <br />r ti <br />❑ <br />Leak detector <br />Onsite Service Technician's Name: / <br />I (�-� k <br />ICC Service Technicianfinstaller Certification #: <br />r <br />Manufacturer Training: <br />L-1 <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />SERVICE <br />Leak detector v C) �- F S ; <br />❑ <br />❑ mechanical Model: <br />A kMJC 0-K S , -fr <br />E electronic Serial #:✓ `iY2LI -� <br />EHD Inspector: \ 1 <br />.� , y t <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ I hour hydrostatic ❑ Incon TS -STS <br />A kMJC 0-K S , -fr <br />❑ Caldwell System ❑ Other <br />EHD Inspector: \ 1 <br />.� , y t <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment repairs for: <br />❑ <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />EHD 23-04 <br />Rev 06/9^/07 <br />f <br />r L <br />'C lrk4 <br />A kMJC 0-K S , -fr <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: \ 1 <br />.� , y t <br />Recei By: <br />. <br />Title: <br />EHD 23-04 <br />Rev 06/9^/07 <br />